Nurse practitioners in medical rehabilitation settings: a description of practice roles and patterns.

PURPOSE: To describe nurse practitioner (NP) roles in medical rehabilitation settings. DATA SOURCE: Description of practice by rehabilitation NPs and physicians. CONCLUSIONS: NPs increasingly function in medical rehabilitation settings as independent or collaborative care providers. This article describes their roles at a large rehabilitation institute in acute care consultation/liaison, acute rehabilitation, and ambulatory settings. The organization has experienced greater physician efficiency and practice scope, without erosion of subjective or objective quality measures and outcomes. The authors provide specific examples of NP roles in intrathecal baclofen and cancer rehabilitation programs. IMPLICATIONS FOR PRACTICE: Advanced practice nurses can provide efficacious care to people with disabilities, resulting in cost savings, improved outcomes, and high value. Patient care by NPs is beneficial for the physicians so that they may extend their clinical realm, spend more time doing research, and participate in medical leadership.

Assessment and evaluation of primary prevention in spinal cord injury.

Although the incidence of spinal cord injury (SCI) is low, the consequences of this disabling condition are extremely significant for the individual, family, and the community. Sequelae occur in the physical, psychosocial, sexual, and financial arenas, making global prevention of SCI crucial. Understanding how to assess and evaluate primary prevention programs is an important competency for SCI professionals. Assessing a program's success requires measuring processes, outcomes, and impact. Effective evaluation can lead future efforts for program design while ensuring accountability for the program itself. The intended impact of primary prevention programs for SCI is to decrease the number of individuals who sustain traumatic injury; many programs have process and outcome goals as well. An understanding of the basic types of evaluation, evaluation design, and the overall process of program evaluation is essential for ensuring that these programs are efficacious. All health care professionals have the opportunity to put prevention at the forefront of their practice. With the current paucity of available data, it is important that clinicians share their program design, their successes, and their failures so that all can benefit and future injury can be prevented.

New approaches to neurorehabilitiation: the increasing evidence base.

Recent advances in neuroscience have led to newer, more scientific approaches to rehabilitation for patients who have had a stroke or sustained a brain or spinal cord injury. Specifically, the pendulum in rehabilitation has swung away from a focus on compensatory techniques and toward impairment-mitigating therapies. In addition, there is a new push to base therapies on scientific evidence. This article explores these changes and the developments that led to them, including discoveries in basic science that have enhanced our understanding of neuroplasticity. It also describes new research directions in neurorehabilitation.

Quality measures for the diagnosis and non-operative management of carpal tunnel syndrome in occupational settings.

INTRODUCTION: Providing higher quality medical care to workers with occupationally associated carpal tunnel syndrome (CTS) may reduce disability, facilitate return to work, and lower the associated costs. Although many workers' compensation systems have adopted treatment guidelines to reduce the overuse of unnecessary care, limited attention has been paid to ensuring that the care workers do receive is high quality. Further, guidelines are not designed to enable objective assessments of quality of care. This study sought to develop quality measures for the diagnostic evaluation and non-operative management of CTS, including managing occupational activities and functional limitations. METHODS: Using a variation of the well-established RAND/UCLA Appropriateness Method, we developed draft quality measures using guidelines and literature reviews. Next, in a two-round modified-Delphi process, a multidisciplinary panel of 11 U.S. experts in CTS rated the measures on validity and feasibility. RESULTS: Of 40 draft measures, experts rated 31 (78%) valid and feasible. Nine measures pertained to diagnostic evaluation, such as assessing symptoms, signs, and risk factors. Eleven pertain to non-operative treatments, such as the use of splints, steroid injections, and medications. Eleven others address assessing the association between symptoms and work, managing occupational activities, and accommodating functional limitations. CONCLUSIONS: These measures will complement existing treatment guidelines by enabling providers, payers, policymakers, and researchers to assess quality of care for CTS in an objective, structured manner. Given the characteristics of previous measures developed with these methods, greater adherence to these measures will probably lead to improved patient outcomes at a population level.

RAND/UCLA Quality-of-Care Measures for Carpal Tunnel Syndrome: Tools for Assessing Quality of Care and Appropriateness of Surgery.

Claims relating to carpal tunnel syndrome (CTS) are common in workers' compensation systems. Given that the human and economic costs related to CTS are considerable, healthcare organizations must be able to offer high-quality care to people affected by this condition. The study on which this article is based is a step toward improving care for CTS. It has produced two unique tools for institutions to use, one for assessing the quality of care received by a population of patients who have or may have CTS, and the other for identifying the appropriateness of surgery for individual patients. Tools that assist in measuring quality of care are fundamental to efforts to improve healthcare quality. Tools that assess the appropriateness of surgery ensure that people who need surgery receive it and, conversely, that people are not subjected to inappropriate operations. Applied in this way, these two tools are likely to improve clinical circumstances and economic outcomes for people with CTS. Together, they can be useful to provider organizations, medical groups, medical certification boards, and other associated decisionmakers attempting to assess, monitor, and provide appropriate care for people with CTS.

Clinical quality measures for electrodiagnosis in suspected carpal tunnel syndrome.

Extensive research has documented that medical care in the United States is not of optimal quality, meaning that well-established care processes are not consistently provided to the patients who would benefit from them. To assess and improve quality of care, specific measures are needed. The objective of this study was to develop quality measures for electrodiagnostic testing in suspected carpal tunnel syndrome (CTS). We used a variation of the well-established RAND/UCLA Appropriateness Method to develop the measures. A physiatrist and quality measurement experts developed draft measures based on guidelines and literature. Subsequently, in a two-round, modified-Delphi process, a multidisciplinary panel of 11 national experts in CTS reviewed a summary of the evidence and then rated the measures for validity and feasibility. Seven draft measures were developed. The expert panel combined two, modified the others, and then judged all resulting measures to be valid and feasible. The measures cover compelling indications for testing, essential test components when CTS is suspected, skin temperature measurement and normalization, and the appropriate interpretation of test results. These measures define a minimum standard of care for the use of electrodiagnostic tests in suspected CTS and are consistent with recent guidelines developed by the American Association of Neuromuscular and Electrodiagnostic Medicine. Provider organizations, insurance companies, and professional societies can use these measures in efforts to monitor and improve quality of care for this common and disabling condition.